Random Thoughts from a Restless Mind

Sunday musings…

1) Triple Crown. Admit it, you really want to see one won next week.

2) Black Hole. Games.CrossFit.com. Seriously. Where did yesterday go?

3) False dichotomy. Kinda like a forced-choice testing paradigm where you’re always wrong.

4) Rich. “The rich are different from the rest of us.” F. Scott Fitzgerald. Perhaps. But what I find fascinating, time and again, is how much the rich and the not-so-rich have in common.

Just take away some something that is truly meaningful that can’t be bought. We’re all the same, then.

5) Impending. I am 54 years old, Mrs. bingo soon to be 53. We are as in the middle as we could possibly be, the filling in the so-called “sandwich generation”. It’s the opposite of what my sage friend Hari once told me about turning 50, that the first 50 years of my life were about preparing and the next 50 were about me. And Mrs. bingo. Yet here we sit, squarely in the middle of lives in “launch” mode, and lives at the limit. So which is it? All about us, or squeezed in the sandwich from both ends of the life line?

Now THAT’S a dichotomy, false or otherwise.

You know, the bingo progeny are going to do just fine. My left-brain knows that; the right-brain angst is probably just separation anxiety. “The Heir”, “Lovely Daughter”, and “Lil’bingo” are all launched, and what their trajectories may be is largely (and appropriately) mostly out of our control, angst be damned. We may have lost the pleasure of their physical company at the dinner table, but we’ve hardly lost them otherwise. The cyber-kitchen table easily extends to each of their abodes.

The real loss to come, the loss of our own parents, is really what makes the “sandwich” so difficult. This stage has always been a participatory sport, and the final score is always the same. It may not even be any different from generations past other than the fact that we have a catchy name for our part now, “sandwich generation”. Most of us do not have our parents in our homes, so the decline we observe is all the more jarring because we see it in “jumps” rather than as a slow slide. As Baby Boomers we probably spend much more time thinking about how this all impacts US than prior generations–we could be called the “Navel-Gazing Generation, after all. In a funny way this actually gives our own parents one more opportunity to parent us by disabusing us of that rather selfish notion.

Memory is the issue for both parent and child. Happy memories bring joy and sadness, pulled to the front of our consciousness as both balm for the pain of loss and fuel for the work it takes to get through a day. Memory fades from the middle out, again for both parent and child. The toil of mid-life and the tyranny of teenagers fades as all that remains is the memory of the simplicity of early childhood joy, and the simple joy of remembering lunch.

We are in the middle of the Long Goodbye. We know not exactly when it began, and we know not how long is will last. We cling to our memories of life before as we fight not to remember life now. Mother’s Day is just past. Another Father’s Day is nigh. We steel ourselves for the time when they will be just another day, one on which we have nothing to visit but memories.

It seems that we are preparing, still, now and always.

I’ll see you next week…

Posted by bingo at June 1, 2014 6:53 AM

It’s become one of those trendy phrases, “unnecessary care”. When you hear it on television or talkshow radio it’s usually said with a sneer. Indeed, the speakers almost spit the phrase out–“Unnecessary care”–like it tastes bad.  It’s almost always accompanied by “fraud and abuse”, or a not so subtle accusation that some doctor is profiting off this “unnecessary care” at the expense of some poor patient. But is this true? Is this always the case? Are there no longer any circumstances whatsoever where the doctor really DOES know best?

I’m an ophthalmologist, an eye surgeon.  Every single day in the office I see several patients who have enormous cataracts which have dramatically affected their vision, and yet they are not only totally unaware of this decrease, they are militant in their rejection of surgery to improve their vision. Some of them have vision which has decreased to a point where, not only would they fail their drivers license test, they are nothing short of a menace to society behind the wheel. Because cataract surgery is an elective procedure, the patient gets to choose whether or  not to proceed with surgery. In other words, operating on a patient with a cataract who does not feel he has a problem would be “unnecessary care”.

The opposite version of this happens every day, too. In about 25 states there are strict, numerical guidelines that insurance companies (including Medicare) used to determine whether or not cataract surgery is “medically necessary”. Not a day goes by when I don’t see a patient who is bitterly unhappy with her vision, and yet her measured visual acuity is better than the threshold for “medical necessity”. Despite the fact that this patient feels handicapped by decreased vision caused by a cataract, operating on her is considered “unnecessary care”.

It kinda tricky. Sort of a damned if you do, damned if you don’t thing. I know it seems like a rather fine distinction, but cataract surgery is actually a big deal when it comes to the economics of medicine in the United States. Did you know that there are almost 3,000,000 cataract surgeries performed every year in the United States? Could some of these surgeries have been “unnecessary”? I dunno. I’m really struggling with the definition of “necessary”, frankly. Is cataract surgery in my two patients unnecessary? Says who?

You can achieve the same relative mortality rates for atrial fibrillation with either a cardiac ablation, or a cocktail of medications. Maybe you are medicine–free with the ablation, and therefore free of not only the yoke of your daily medicine schedule and side effects, but also the considerable burden of navigating your health insurance-approved medication list. The ablation might be 10X the cost of the medicines, but does that make it “unnecessary”? Too much? Says who?

So how do these two cataract patient scenarios play out at Skyvision? Well, the very unhappy patient with a cataract of any size whose vision does not reach that threshold level of “medical necessity” always chooses to wait until her insurance will pay for the cataract surgery. Always, whether she is a retired schoolteacher or a wealthy heiress worth tens of millions of dollars. She leaves the office unhappy, frustrated, and frightened. She cannot enjoy her daily activities because she cannot see well enough, and she is frightened by the prospect of normal activities like driving.

The other patient? Well, this patient typically has a monstrous cataract, so brown and cloudy it’s like looking through beef broth, or even beef gravy. This patient gets angry, too, but he is angry at me. He’s angry and offended that I would have the audacity to suggest that his vision is poor, too poor to drive, for example. He doesn’t understand what 20/50, or 20/80, or 20/100 vision means, and frankly he doesn’t really care. He’s got a drivers license, dammit, and he’s legal to drive. These visits almost always end something like this:

Me: “What kind of car do you drive?”

Patient: “A crown Vic.”

Me: “What color is your Crown Vic?”

Patient:” White. Why?”

Me: “Because my wife and kids are driving on the same roads as you, and I’m going to tell them to stop and pull over every time they see a white Crown Victoria.”

I say THAT’S “necessary care”!